Volume 44 Number 1 pp. 22-41 2018

Original Research

Clinical effectiveness evaluation of laser therapy and in treatment of patients with myofascial pain in masseter muscle

Diego A. Oliveira (Federal University of Juiz de Fora)

Rafael de Almeida Spinelli Pinto (Federal University of Juiz de Fora, [email protected])

Larissa de Oliveira Reis (Federal University of Juiz de Fora)

Isabela Maddalena Dias (Centro Universitario Estacio de Sa)

Isabel Cristina Goncalves Leite

Fabiola Pessoa Pereira Leite

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Suggested Citation Oliveira, D. A., et al. (2018). Clinical effectiveness evaluation of laser therapy and dry needling in treatment of patients with myofascial pain in masseter muscle. International Journal of Orofacial Myology, 44(1), 22-41. DOI: https://doi.org/10.52010/ijom.2018.44.1.2

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

The views expressed in this article are those of the authors and do not necessarily reflect the policies or positions of the International Association of Orofacial Myology (IAOM). Identification of specific oducts,pr programs, or equipment does not constitute or imply endorsement by the authors or the IAOM. International Journal of Orofacial Myology 2018, V44

CLINICAL EFFECTIVENESS EVALUATION OF LASER THERAPY AND DRY NEEDLING IN TREATMENT OF PATIENTS WITH MYOFASCIAL PAIN IN MASSETER MUSCLE Diego Azi de Oliveira DDS, Rafael de Almeida Spinelli Pinto DDS MS, Larissa de Oliveira Reis DDS MS, Isabela Maddalena Dias DDS MS PhD, Isabel Cristina Gonçalves Leite DDS MS PhD, Fabíola Pessôa Pereira Leite DDS MS PhD

ABSTRACT

Myofascial pain is considered a type of muscular TMD, being common in patients with musculoskeletal pain associated with active or latent trigger points. Among the therapeutic options, there are low-intensity laser therapy and dry needling. The aim of this study was to compare the efficacy of these two therapies in the masseter muscles of patients with myofascial pain. Ten patients diagnosed with myofascial pain, with or without limitation of mouth opening, were randomly divided into two groups for treatment with low intensity laser therapy (G1) (n = 5) or dry needling (G2) (n = 5). The pain symptomatology and the mouth opening measurement were evaluated weekly before the start of treatment, and one week after the final treatment. The comparison between G1 and G2 in relation to the improvement in mouth opening was not statistically significant (p> 0.05). However, dry needling (G2) has shown numerically to be more effective than laser therapy in a shorter period comparing initial and final mouth opening. Regarding the pain symptomatology, both therapies were effective comparing the initial and final evaluations of patients with myofascial pain (p <0.05).

KEYWORDS: Temporomandibular ; Temporomandibular Joint Disorders; Dry needling; Laser Therapy Trigger points; Myofascial pain.

INTRODUCTION

According to the American Academy of muscles, temporomandibular joint (TMJ) and Orofacial Pain, Temporomandibular Disorder associated structures (Okeson, 2013). TMD is (TMD) is a term that covers a large number of considered a sub-classification of clinical problems affecting the masticatory musculoskeletal dysfunctions and typically

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presents a recurrent or chronic course with a various nociceptive chemicals, including substantial fluctuation of its signs and bradykinin, CGRP, and P-substances symptoms over time (Andrade & Frare, 2008). associated with the pain sensing mechanism. Bradykinin is a nociceptive agent that Myofascial pain is considered a common stimulates the release of tumor factor diagnosis in patients with musculoskeletal pain and interleukins, from which they can stimulate associated with active or latent myofascial the release of another bradykinin (Dommerholt, Trigger Points (TP). (Han & Harrison, 1997; 2011). These algogenic substances create a Alvarez & Rockwell, 2002; Cagnie, Dewitte, hypersensitivity local zone at the muscle, and a Barbe, Timmermans, Delrue & Meeus, 2013). raised temperature at TP areas, suggesting a TP are defined as a very sensitive point in a metabolic or blood flow increase at these tight band of fibers that, tissues (Okeson, 2013). The diagnosis of TP spontaneously or by compression, causes local is made by physical examination, which must pain and in a distant region from the stimulated consider the physical signs including presence one, known as (Lin, Kaziyama & of palpable tension in a musculoskeletal area, Teixeira, 2001). The muscle tension band presence of hypersensitive nodules in the area restricts muscle resulting in limitation of muscular tension, visible or palpable local of movement, muscle shortening, decreased contraction upon compression (Lavelle, Lavelle muscle function effectiveness, and pain & Smith, 2007). induced by muscle inhibition. Coordination is affected as well as the reflex inhibition of the Treatment options include pharmacological antagonistic activity of the muscles (Pearce, and non-pharmacological interventions. In 2004). An active TP causes spontaneous pain pharmacological methods non-steroidal anti- in response to movement, stretching or inflammatory drugs and narcotic medications compression of the affected site, while a latent are used for control of the symptoms. Non- TP is considered a sensitive point with pain or pharmacological methods include physical discomfort in response only to compression therapy, stabilizing splints, sprays and (Hong, 2006; Kuan, 2009). (Rayegani, Bayat, Bahrami, Raeissadat, Kargozar, 2014). Physical Through histological studies, it was confirmed therapies include postural training, exercises to that the presence of extreme sarcomeres extend and relax muscles, increase range of contraction, resulting in tissue hypoxia, with motion, reduce cracking and stabilize the TMJ. the oxygen saturation in a TP is less than 5% Physical agents include electrotherapy, at normal. Hypoxia leads to the local release of ultrasound, iontophoresis, analgesic agents,

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, low intensity laser therapy (LILT) (Kalichman & Vulfsons, 2010; Rayegani et al., and dry-needling (DN). LILT and DN are 2014). This method has been used more considered to be effective interventions for the frequently for the control of muscular pain, not treatment of myofascial pain (Venâncio, only for the reduction of pain, but also for the Camparis & Lizarelli, 2002; Catão, Oliveirta, advantages associated with a simple Costa & Carneiro 2013). methodology for clinical applications, cheaper application materials and less risky procedures LILT is a non-pharmacological, non-invasive (Chou, Kao & Lin, 2012; Ziaeifar, Arab, Karimi and low-cost modality that has been widely & Nourbakhsh, 2014). used in physiotherapeutic clinical practice for the relief of pain and tissue regeneration (Kato, Sensory stimulation caused by DN promotes Kogawa, Santos & Conti., 2006; Fikackova, the mechanical rupture of dysfunctional Dostálová, Vosická, Peterová, Navrátil & terminal plates integrity corresponding to the Lesák, 2006; Melchior, Machado, Magri, & place where TP develops (Chou, Kao & Lin, Mazzeto, 2016). This therapeutic modality 2012). This stimulus promotes a blocking provides regulation of cellular physiological effect on the dorsal intra-cortical nontoxic functions, mediation of inflammatory information passage (which causes tissue processes, potentiation of tissue repair damage and consequent pain sensation) processes, and promotion of analgesia in generated by the TP nociceptors with the cases of acute or (Venâncio et al. consequent relief of myofascial pain (Chu, 2002; Sanseverino, 2001; Catão et al., 2013; 1995). Shukla & Muthusekhar, 2016). The literature has shown satisfactory results with LILT in the According to the literature both techniques deactivation of TP and decrease of myofascial have good efficacy in the treatment of muscular pain, resulting in functional ability improvement pain. In the study by Andrade & Frare (2008) and patients life quality when applied correctly LILT associated with (Simunovic, 1996; Gür, Sarac, Cevik, Altindag techniques obtained statistically significant & Sarac., 2004; Carrasco, Guerisoli, Guerisoli reduction of pain symptomatology compared to & Mazzeto, 2009; Kannan, 2012; Uemoto, the group treated only with manual therapy Garcia, Gouvêa, Vilella & Alfaya, 2013). techniques when comparing pre and post treatment values after application of visual DN technique consists basically of inserting the analog scale. In the same sense, in a study by needle directly into the TP without the use of Farias, (2005), electromyography was able to any medication, stimulating local pain relief obtain electrical activity records of TP in

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masseter muscle before and after the LILT while those that started with mild pain (value application, demonstrating that there was less than 6) the expected reduction of pain was relaxation and analgesia of the muscle with 4 points or less. consequent increase of mouth opening amplitude. The aim of this study was to compare the therapeutic effects of LILT and DN in Ferreira, de Oliveira, Guimarães, Carvalho A & individuals who presented myofascial pain in De Paula (2013), showed that laser the masseter muscle. acupuncture was efficient in obtaining complete remission of the symptoms of METHODS temporomandibular and myofascial pain after 3 months of treatment and promoted greater and This project was approved by the Ethics faster reduction of the symptoms in comparison Committee on Human Research of the Federal with the placebo group. Furthermore, for University of Juiz de Fora (Minas Gerais, patients in whom conservative treatment was Brazil). adopted, the laser acupuncture was a secure, noninvasive, and effective treatment modality Ten patients aged 18 to 70 years old, with because it improves the chronic pain orofacial pain complaints, were referred to the associated with TMD and has no side effects. Diagnostic and Guidance Service for Patients with Temporomandibular Disorder (Serviço Regarding the studies on DN, in the study by ATM) of the Faculty of Dentistry of Federal Fernández-Carneiro, La Touche, Ortega- University of Juiz de Fora (UFJF). Patients in Santiago, Galan-del-Rio, Pesquera, Ge, et al. myofascial pain treatment and with systemic (2010), the application of dry needling of active diseases such as , arthrosis, TP in masseter muscle induced significant jaw arthritis and rheumatism were excluded. opening when compared to sham dry needling (placebo group) in TMD patients. In the same The diagnosis of myofacial pain was confirmed sense Gonzáles-Perez, Infante-Cossio, through Research Diagnostic Criteria (RDC / Granados-Nuñes & Urresti-Lopez (2012), after TMD - Axis I) (Dworkin & Le Resche, 1992), evaluation of TP in the external pterygoid applied by a single examiner, specialist in TMD muscle observed that in those patients who area. This diagnosis was considered when the had significant pain before starting treatment presence of myofascial pain with limitation of (values 8 to 10 in visual analog scale), it was mouth opening, and when the opening common that they had a reduction of 6 points, (unassisted and without pain) measurement

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was less than 40 mm, according to item 4 from measured according to item 4 from RDC/DTM - RDC / DTM - Axis I, in which the edge of a Axis I. millimeter ruler is placed at the incisal edge of the maxillary central incisor that is the most Ten patients selected were randomly and vertically oriented and then measured vertically divided into two groups of 5 individuals each to the labioincisal edge of the opposing one: Group 1 (G1) (n = 5) submitted to LILT; mandibular incisor. The maxillary incisor Group 2 (G2) (n = 5) submitted to DN. The chosen was indicated on the form for each application of each therapy method was patient. contraindicated in areas with wounds, spots or scars. The criteria established by Travell & Simons (1999) were used to diagnose active and latent G1 patients were provided with12 LILT TP: presence of a palpable muscle tension sessions once a week according to the band with a hypersensitive point, as protocol of Venâncio et al. (2002). TP were well as a sensory abnormality or referred pain identified with a ballpoint pen so that they could produced by TP. For active TP, this referred be precisely located during the procedure pain should correspond to the individual's (Figure 1). The application was done in a existing pain complaint. The hypersensitivity of punctual way and in perpendicular contact with TP was confirmed by the patient's "jump sign", the skin, bilaterally (Figure 2), with LILT which can be manifested by facial expressions equipment, previously calibrated, with red light such as grimaces, verbal responses that signal source at 660nm wavelength (Whitening Lase pain, or by movement of the body to escape II DMC Equipamentos, São Carlos, SP, Brazil), the pain. energy density of 40 J / cm², average power of 40 mW or 1.6 J of total energy, continuous Before the starting the treatment the pain emission mode for 40 seconds with the intensity of each participant was measured conventional tip. The physical evaluation according to the Visual Analogue Scale (VAS), symptoms were recorded at thirteen different graded from 0 to 10 in which 0 represents times, corresponding to the session before the absence of pain and 10 represents the highest beginning of the treatment and the 12 sessions degree of discomfort in which patients of LILT application, in order to visualize the indicated the painful sensation at the time of symptomatic evolution of the individuals in the the examination. In addition, the initial measure sample. of mouth opening of each patient was

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Figure 1: TP marked with ballpoint pen.

Figure 2: LILT application bilaterally.

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G2 patients were provided with 6 sessions of long. After the needle insertion, smooth and DN, unilaterally in 2 patients and bilaterally in 8 rotating movements were performed for 1 patients, according to the complaint of where minute in each TP (Figure 3). In cases of pain the patient was experiencing pain and the after the procedure, thermotherapy was presence of TP. DN was made with sterile recommended with ice or moist heat in the acupuncture needles (DongBang painful area. After finishing the treatments, the Acupuncture®, Boryeong, Chungnam, Korea) mouth opening measurements were done with a 0.25 x 30mm caliber and 5cm long again according to item 4 from RDC / TMD - enveloped by a cylindrical plastic holder 4.5cm Axis I.

Figure 3: Rotating movements made with the needle during the DN technique.

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According to the analysis of all DN and LILT measurements at the first moment (M1) and sessions, the mean of individual symptom the moment after treatment (M13) were grade of both groups was calculated, in order compared, as well as VAS measurements to compare the pain level of each patient and using ANOVA test. Statistical analysis of the of each sample before and after the end of the results was done using software SPSS 14.0 treatments. Absolute and relative frequencies and Epi Info 6. The Kolmogorov-Smirnov test and descriptive measurements were obtained showed normal distribution of quantitative for continuous data (means and respective measures (p> 0.05). standard deviations). Mouth opening

RESULTS

The sample was composed of 10 female patients, with mean age of 39.2 years old.

GROUP 1: The patients frequency in G1 diagnosed with TMD, according to RDC / TMD Axis I, is described in Table 1. Regarding the number of TP identified in G1, the total mean was approximately 5 points marked on each side of the face.

Table 1: Diagnosis frequency of TMD in patients evaluated for treatment with LILT (G1). TMD Diagnosis Frequency – n (%) Muscle Disorder Myofascial pain 1 (20%) Myofascial pain with opening limitation 2 (40%) Disk Displacement With reduction 2 (40%) Without reduction with opening limitation 1 (20%) Without reduction without opening 0 (0%) limitation Arthralgia, Arthritis or Arthrosis Arthralgia 0 (0%) Arthritis 0 (0%)

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The measurement of mouth unassisted and without pain, before and after G1 treatment is described in Table 2 (RDC / DTM - Axis I, item 4).

Table 2: Measurement of mouth opening without help and without pain before (initial) and after one week of the end (final) treatment with LILT (G1). Moment Minimum Maximum Mean (mm) Standard (p) (mm) (mm) Deviation (mm) Initial 35 44 38 4,243 p=0,72 Final 44 50 35,2 3,564

The maximum mouth opening measurement unassisted, even with discomfort before and after G1 treatment, is described in Table 3 (RDC / DTM - Axis I, item 4).

Table 3: Measurement of maximum mouth opening without help before (initial) and after one week (final) of treatment with LILT(G1).

Moment Minimum Maximum Mean (mm) Standard (p) (mm) (mm) Deviation (mm) Initial 42 55 47,4 5,550 p=0,31 Final 44 50 46,4 2,302

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The weekly value of VAS and its respective mean values at each time of G1 treatment are described in Table 4.

Table 4: Measurement of VAS individually and respective means and standard deviation according to the moments of treatment with LILT (G1). PATIENTS (VAS) Total Standard Mean Deviation MOMENTS 1 2 3 4 5 M1 6 5 10 6 7 6,8 1,923 M2 5 6 8 7 7 6,6 1,14 M3 3 5 10 6 7 6,2 2,588 M4 4 1 9 5 5 4,8 2,863 M5 3 0 10 3 4 4 3,674 M6 1 1 6 3 5 3,2 2,28 M7 1 0 6 4 5 3,2 2,588 M8 2 0 6 5 4 3,4 2,408 M9 2 0 8 4 4 3,6 2,966 M10 2 0 8 3 5 3,6 3,049 M11 1 0 9 2 5 3,4 3,646 M12 3 0 9 2 3 3,4 3,361 M13 2 0 8 2 3 3 3

Considering the mean value of VAS in M1 showed a statistically significant difference (p before treatment up to M5, no significant <0.05), showing improvement in the index of statistical difference was found (p> 0.05). pain indicated by patient However, from M6, the comparison with M1 .

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GROUP 2 The patients frequency in G2 diagnosed with TMD, according to RDC / TMD Axis I, is described in Table 5. Regarding the number of TP identified for DN, considering all patients, TP total mean per side was approximately 4 points marked in each patient's face.

Table 5: Diagnosis frequency of TMD in patients evaluated for treatment with DN (G2). TMD Diagnosis Frequency – n (%) Muscle Disorder Myofascial pain 1 (20%) Myofascial pain with opening limitation 4 (80%) Disk Displacement With reduction 1 (20%) Without reduction with opening limitation 0 (0%) Without reduction without opening 0 (0%) limitation Arthralgia, Arthritis or Arthrosis Arthralgia 2 (40%) Arthritis 0 (0%)

The measurement of mouth opening unassisted and without pain, before and after G2 treatment is described in Table 6 (RDC / DTM - Axis I, item 4).

Table 6: Measurement of mouth opening without help and without pain before (initial) and after one week of treatment end (final) with DN (G2). Moment Minimum Maximum Mean (mm) Standard (p) (mm) (mm) deviation (mm) Initial 23 42 31,9 6,789 p=0,17 Final 25 48 36,2 6,460

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The maximum mouth opening measurement unassisted, even with discomfort before and after G2 treatment, is described in Table 7 (RDC / DTM - Axis I, item 4).

Table 7: Measurement of mouth opening without help and without pain before (initial) and after one week of treatment end (final) with DN (G2). Moment Minimum Maximum Mean (mm) Standard (p) (mm) (mm) deviation (mm) Initial 32 49 39,6 5,501 p=0,17 Final 32 52 43,1 5,567

The weekly value of VAS and its respective mean values at each time of G2 treatment are described in Table 8.

Table 8: Measurement of VAS individually and respective means and standard deviation according to the moments of treatment with DN (G2). MOMENTS PATIENTS (VAS) Total Mean Standard Deviation 1 2 3 4 5

M1 10 8 7 7 9 8,3 1,494 M2 8 0 3 6 5 5,5 3,472 M3 5 5 3 8 9 6,1 2,998 M4 3 0 3 6 1 3,3 2,497 M5 0 0 0 5 5 2,6 2,836 M6 0 0 3 7 0 3,4 2,675 M7 1 0 0 6 0 2,3 2,869

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The comparison between the values of initial and final mouth opening unassisted and without pain and initial and final maximum mouth opening unassisted did not show significant statistical differences as demonstrated in Figure 4 and Figure 5

39 38 37 38 36.2 36 35

34 35.2 G1 p=0,296

mm 33 G2 p=0,339 32 31 31.9 30 29 28 Initial Final

Figure 4: Initial and final pain comparison of mouth opening without help and painless between G1 and G2.

48

46 47.4 46.4 44

42 43.1 G1 p= 0,725 mm 40 G2 p=0,351 38 39.6

36

34 Initial Final

Figure 5 Initial and final pain comparison of mouth opening without help between G1 and G2.

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Considering the mean value of VAS in M1 Comparing the groups based on the results before treatment up to M3, no significant obtained from the initial and final VAS mean of statistical difference was found (p> 0.05). each treatment, no significant statistical However, from M4, the comparison with M1 difference was observed between the showed a statistically significant difference (p treatments, both of which provided significant <0.05), showing improvement in the index of improvements in patients' pain and quality of pain indicated by patient. life (Figure 6) .

9 8.3 8 7 6 6.8 5

mm G1 p=0,05 4 3 3 G2 p<0,001 2 1 2.3 0 Initial Final

Figure 6: Comparison of VAS results between G1 and G2 and p values respectively.

DISCUSSION symptoms of TMJ dysfunction in women due to estrogen and prolactin, which can exacerbate The sample of the present study was the degradation of articular cartilage and bone, composed entirely of female patients (n = 10) as well as stimulate a series of immune with mean age of 39.2 years. According to Le responses in these . Another relevant Resche, Saunders, Von Korff, Barlow & cause is the fact that women present higher Dworkin (1997), TMD presents higher stress indexes than men, resulting in a higher prevalence in women at reproductive age, with incidence of diseases with psychosomatic reduction in the prevalence in the involvement (Penna & Gil, 2006). postmenopausal period, suggesting an important relation with the hormonal oscillation. LILT increases the cell membrane permeability Ilha, Rapoport, Ilha Filho, Reis & Boni (2006) allowing it to function effectively, which suggest that there is an increase of the accelerates tissue healing, increasing the

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release of endorphin (Chow, Heller & Barnsley, noted, for example, protective co-contraction 2006). DN is effective in the treatment of that alters normal muscle activity, in the musculoskeletal pain by providing muscle presence of some with the main intention relaxation through stimulation of the of protecting the part threatened. This may be endogenous suppressor pain system bringing clinically noted as an opening limitation, which better sleep quality and decreasing anxiety may justify the results that are not statistically (Lavelle et al., 2007). significant between the values measured before and after treatment found in the present Despite the small number of patients in the study. sample, the evaluation of pain by VAS demonstrated, numerically, better results from Uemoto et al. (2013), demonstrated that the DN in relation to LILT. The Uemoto, Azevedo, two therapeutic modalities did not produce Alfaya, Reis, Gouvêa & Garcia study (2013), in significantly better results in relation to mouth which only the DN group also showed a opening because the application was exclusive significant symptom improvement. to the masseter muscle and may not have provided the relaxation of other muscles There is still disagreement in the literature participating in the mandibular movements. In regarding the number of clinical sessions for agreement with the present study, besides the LILT and DN therapies. As in the present application of the techniques only in the study, Simunovic (1996) recommends the laser masseter muscle, it was observed that the application two or three times a week, but presence of other concomitant TMD diagnoses, Venâncio et al. (2002) suggests a larger suggesting possible influence on values of number (30 sessions) for decrease of pain. In mouth opening. addition, Cagnie et al. (2013) showed that after 20 sessions of DN, there was functional and LILT and DN, as suggested by the literature, pain relief in patients evaluated, disagreeing represent alternatives to the treatment of with the present study. patients with myofascial pain, constituting effective and non-invasive methods. It is The maximum mouth opening and the extremely important for the professional to presence of disorders in each individual varies have the knowledge and understanding of the according to gender (Bianchini, 2000; Manfredi, proper execution of the techniques when Silva & Vendite 2001). Okeson (2013), states determining a treatment plan in order to that other central excitatory effects, beyond the decrease and relieve the patients pain. referred pain by the presence of TP can be

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CONCLUSIONS laser therapy for the deactivation of TP, there is a lack of clinical trials comparing the two LILT and DN in the masseter muscle were techniques. Considering the small sample and effective in reducing symptomatology of the importance of these therapies, further patients with myofascial pain. DN was controlled studies are needed on this subject, demonstrated numerically to be more effective including the association with other muscle than LILT in a shorter period of sessions when regions as SCM, with the objective of the initial and final mouth opening was promoting an efficient treatment for patients evaluated. Although studies have with myofascial pain. demonstrated the efficacy of dry needling and

CONTACT AUTHOR

Rafael de Almeida Spinelli Pinto DDS MS Isabela Maddalena Dias DDS MS PhD School of Dentistry Federal University of Juiz School of Dentistry - Centro Universitário de Fora (Rua José Lourenço Kelmer, s/n. Estácio de Sá Juiz de Fora (Av. Pres. João Campus Universitário São Pedro, Juiz de Goulart, 600 Cruzeiro do Sul, Juiz de Fora Fora MG, 36036-330. Voice 55 (32) 99921- MG, 36030-142. 2210, e-mail. [email protected]. Isabel Cristina Gonçalves Leite DDS MS Diego Azi de Oliveira DDS School of PhD School of Dentistry Federal University of Dentistry Federal University of Juiz de Fora Juiz de Fora (Rua José Lourenço Kelmer, s/n. (Rua José Lourenço Kelmer, s/n. Campus Campus Universitário São Pedro, Juiz de Universitário São Pedro, Juiz de Fora MG, Fora MG, 36036-330. 36036-330. Fabíola Pessôa Pereira Leite DDS MS PhD Larissa de Oliveira Reis DDS MS School of School of Dentistry Federal University of Juiz Dentistry Federal University of Juiz de Fora de Fora (Rua José Lourenço Kelmer, s/n. (Rua José Lourenço Kelmer, s/n. Campus Campus Universitário São Pedro, Juiz de Universitário São Pedro, Juiz de Fora MG, Fora MG, 36036-330. 36036-330.

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